Fall 2014 Canadian Chiropractic Association Magazine - Back Matters Ethics Piece
By Dr. Richard Brown, past president of the British Chiropractic Association (BCA)

Article by Dr. Richard Brown We live in an age where medical science has revolutionized the provision of healthcare. Harnessing the inexorable advance of technology with the brilliant minds of researchers has given rise to an age of lifechanging discoveries and previously inconceivable medical procedures.

Telemedicine and surgical robots mean that procedures can be remotely performed in theatres far from the surgeon's physical location. We can produce 3D images of almost any part of the body, and laboratory testing of blood and human tissue can diagnose the majority of human ailments.

As a consequence of medical advances and better living standards, we are living longer. Over 30 nations have an average life expectancy exceeding 80 years, with Monaco (87) and Japan (85) topping the charts. According to the UK Office for National Statistics, 1/3 of babies born last year will live to be 100 years old. We can expect not just years, but decades of life following retirement.

However, all is not as utopian as it seems. While it has extended life expectancy, medical technology is expensive and public demand has created a potentially unsustainable financial burden on our current model of healthcare. Experts predict that spiralling costs will bankrupt governments if the provision of healthcare is not transformed.

Spinal pain has been described as the scourge of western society. Reaching epidemic proportions, low back pain is the number one cause of global disability, with neck pain ranking 4th and 'other musculoskeletal disorders' in 6th place.1 Yet despite all of the advances in medical science, spinal pain remains poorly managed in mainstream care and, without a sustainable solution, costs millions in lost productivity and disability payments.

In our 21st century healthcare environment, patients are too often reduced to a sheet of data or an isolated image on a computer screen. Impersonal communications from anonymous data controllers demand attendance at clinics where they are seen by any one of a number of medical specialists who have no personal knowledge of their patients. Tests are conducted, scans are performed and the attainment of targets is sought. Dwindling resources have created high stress environments where the elderly worry they are burdensome and the voices of patients are perceived as being unheard.

As government healthcare workers rue the fact that their daily business is now more driven by completing audit trails and cost analyses than attending to their patients we cannot help but wonder if the values once held dear to health professionals has been sacrificed on the altar of advancement. What has been lost in the provision of modern healthcare?

From time immemorial, manual therapy has had a place in healthcare. As far back as 400 BC, great writers and philosophers were extolling the virtues of a handson approach to care. Hippocrates, often referred to as the father of medicine, described methods of spinal manipulation for treating scoliosis, while Galen wrote of standing or walking on the spine. Variously, physicians, bone setters and shamans wrote of their successes in treating medical and musculoskeletal conditions by hand. Where other solutions did not exist, the power of manual medicine was of great influence.

Orthodox physicians in the 15th and 16th centuries further described methods of manual treatment of the spine before the techniques once again fell into the hands of 18th century bone setters. However, the founding of the chiropractic and osteopathic professions and the continued success of bone setters towards the end of the 19th century led the founder of British Orthopaedics, Robert Jones, to comment: "We should mend our ways rather than abuse the unqualified. Dramatic success in their hands should cause us to enquire as to the reason. It is not wise or dignified to waste time denouncing their mistakes, for we cannot hide the fact that their successes are our failures."2

It is unsurprising that manual therapy survives as a valued intervention. In a modern age where medicine can be delivered without the presence of the patient, there is a sense that the traditional relationship between the physician and patient is in decline and, despite scientific evidence supporting technological innovation, patients continue to value the intimacy of the traditional healthcare relationship. It is, therefore, no accident that the enduring success of chiropractic and osteopathy owes itself to utilizing the power of assessment, treatment and care through human touch.

Article by Dr. Richard Brown The human hand itself is a miracle of bioengineering. The mere anatomy, with its complex arrangement of bones, muscles, ligaments and nervous tissue, is a triumph of design and allows us to undertake complex tasks simultaneously. While robot technology to mimic human hand movements exists, it has still not mastered the complex dexterity of fine motor movements. Yet the properties of the human hand do not end there. The complexity of its sensory abilities and central nervous connections allow for detection and communication of emotional states and non-verbal cues.

The power of the human hand should not be underestimated. From the outset of our lives, touch communicates comfort, reassurance and a sense of wellbeing. From birth, bonding is achieved by touch and the very essence of the relationship between parents and their children is based on human contact and physical proximity. Children are comforted by parental and sibling hugging and hand-holding, and those who are deprived of such contact often become psychologically damaged and even physically stunted. The neurochemical effects of touch are well-documented, with reduced levels of oxytocin, known as one of the 'happiness molecules', having been detected in those denied of skin-toskin contact.

The demise of human contact in healthcare is a concern. Some years ago, a primary care trust in the UK announced that physiotherapy was to become non-contact, with patients being prescribed exercise rather than receiving manual methods of care. The public outcry that followed reflected the value that patients place in hands-on care and the intimacy of the physicianpatient relationship. Frequently, complaints by patients against practitioners allege that they were not examined or that 'the doctor did not even touch me'.

Technology reduces the need for human contact. Although this may be welcomed by advocates of safeguarding, distancing health professionals from their patients impacts the psychosocial elements of care. Traditional images of a care-giver holding the hand of a distressed patient or putting a comforting arm around the shoulder of the recently bereaved are being replaced by colder, clinical relationships in which compassion is notably absent.

Sadly, suspicion has also driven a move towards a more hands-off approach to care. Medico-legal considerations and the fear of any contact being misconstrued as sexualized behaviour have resulted in a reluctance of some practitioners to even shake the hands of some patients for fear of facing accusations of impropriety. Society must continue to champion the power of the human hand and the value of human touch. It is the very foundation of establishing a bond of trust between practitioner and patient; it is the very essence of what healthcare — in its truest sense — must comprise. As health systems are transformed to combat the domination of cost-prohibitive technological interventions, so must the value of touch be promoted in the care of our patients.

As chiropractors, we have the skills to change lives for the better. We have the training to detect distinct areas of joint dysfunction and subtle changes in soft tissues. We have the power to provide the relief of pain through skilled adjustments and manual manipulation. Through touch, we have the ability to convey compassion, empathy, reassurance and comfort.

While the science of medicine advances and both diagnostic and therapeutic modalities evolve to provide ever-greater means of prolonging life, we must not forget or forsake the art of healing by hand.

Cheiro-praktos – done by hand – has been the fundamental tenet of chiropractic care for nearly 120 years. It has survived precisely because it has not lost sight of the fact that manual methods of healthcare remain a specialized science and distinct art. Our challenge is to expand the influence of manual therapies as opportunities arise in transformational health systems. To ensure that chiropractors are ready and equipped to seize those opportunities requires consensus on identity, continued high levels of education, a focus on promoting the chiropractic profession as experts in the treatment of musculoskeletal conditions and a commitment to work as part of an integrated healthcare team. Our future is, literally, in our hands.
References:
  1. Hoy D., March L., Brooks P, Blyth F., Woolf A., Bain C., Williams G., Smith E., Vos T., Barendreg J., Murray C., Burstein R., Buchbinder R., The global burden of low back pain: estimates from the Global Burden of Disease 2010 study, Ann Rheum Dis doi:10.1136/annrheumdis-2013-204428
  2. Pettman, E., A History of Manipulative Therapy, J Man Manip Ther. 2007; 15(3): 165–174.